Myriam J. Curet

Laparoscopy During Pregnancy

OBJECTIVE To compare the safety and efficacy of laparoscopic surgery with that of open laparotomy in pregnant patients. DESIGN Six-year case-control study. SETTING Tertiary care, university and community hospitals. PATIENTS Population-based sample. From 1990 through 1995, 16 pregnant patients underwent laparoscopic surgery (study group) and 18 underwent open laparotomy (control group) during the first or second trimester. Follow-up ranged from 1 month to 6 years. INTERVENTION In the study group, 4 patients underwent appendectomies and 12 underwent cholecystectomies. The control group included 7 appendectomies and 11 cholecystectomies. MAIN OUTCOME MEASURES The 2 groups were compared for age, trimester, surgical time, oxygen saturation, end-tidal carbon dioxide, return of gastrointestinal tract function, duration of intravenous or intramuscular narcotics, postoperative stay, gestational age of delivery, 1- and 5-minute Apgar scores, birth weights, and complications. RESULTS Age, trimester, oxygenation, end-tidal CO2, gestational age at delivery, Apgar scores, and birth weights were not different between the 2 groups. The patients who underwent laparoscopy had significantly longer operative times 82 vs 49 minutes), shorter stay (1.5 vs 2.8 days), earlier resumption of regular diet (1.0 vs 2.4 days), and shorter duration of intravenous or intramuscular narcotics (1.2 vs 2.6 days) (all P < .01). Four complications were found in the laparotomy group vs 6 in the laparoscopy group. CONCLUSIONS Laparoscopic surgery in pregnant women significantly decrease hospitalization, decreases narcotic use, and quickens return to a regular diet when compared with open laparotomy in pregnant women. No significant differences between the 2 groups in perioperative morbidity or mortality were present. These data suggest that therapeutic laparoscopy during pregnancy in the first or second trimester is safe.

A consensus document on robotic surgery

“Robotic surgery” originated as an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted by the medical community. The term refers to surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term for current devices would be “remote telepresence manipulators” because available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon. For example, in laparoscopic surgery, the surgeon directly controls and manipulates tissue, albeit at some distance from the patient and through a fulcrum point in the abdominal wall. This differs from the use of current robotic devices, whereby the surgeon sits at a console, typically in the operating room but outside the sterile field, directing and controlling the movements of one or more robotic arms. Although the surgeon still maintains control over the operation, the control is indirect and effected from an increased distance. This definition of robotic surgery encompasses micromanipulators, remotely controlled endoscopes, and console-manipulator devices. The key elements are enhancements of the surgeon’s abilities—be they vision, tissue manipulation, or tissue sensing—and alteration of the traditional direct local contact between surgeon and patient.

The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a widely performed bariatric operation. Preoperative factors that predict successful outcomes are currently being studied. The goal of this study was to determine if preoperative weight loss was associated with positive outcomes in patients undergoing LRYGBP. Methods: A retrospective analysis was performed of all patients undergoing LRYGBP at our institution between July 2002 (when a policy of preoperative weight loss was instituted) and August 2003. Outcome measures evaluated at 1 year postoperatively included percent excess weight loss (EWL) and correction of co-morbidities. Statistical analysis was performed by multiple linear regression. P<0.05 was considered significant. Results: The study included 90 subjects. Initial BMI ranged from 35.4 to 63.1 (mean 48.1). Preoperative weight loss ranged from 0 to 23.8% (mean 7.25). At 12 months, postoperative EWL ranged from 40.4% to 110.9 % (mean 74.4%). Preoperative loss of 1% of initial weight correlated with an increase of 1.8% of postoperative EWL at 1 year. In addition, initial BMI correlated negatively with EWL, so that an increase of 1 unit of BMI correlated with a decrease of 1.34% of EWL. Finally, preoperative weight loss of >5% correlated significantly with shorter operative times by 36 minutes. Preoperative weight loss did not correlate with postoperative complications or correction of co-morbidities. Conclusions: Preoperative weight loss resulted in higher postoperative weight loss at 1 year and in shorter operative times with LRYGBP. No differences in correction of co-morbidities or complication rates were found with preoperative weight loss in this study. Preoperative weight loss should be encouraged in patients undergoing bariatric surgery.

Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long-term outcome.

AbstractBackground: The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer. Methods: A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years). Results: No port-site or abdominal wall recurrences were noted in any patients. Conclusions: These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages.

SPECIAL PROBLEMS IN LAPAROSCOPIC SURGERY: Previous Abdominal Surgery, Obesity, and Pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

Single-Port Robotic Cholecystectomy: Results From a First Human Use Clinical Study of the New da Vinci Single-Site Surgical Platform

OBJECTIVES To report our results from a first human use clinical study with the da Vinci Surgical single-site instrumentation in patients with gallbladder disease and to perform a retrospective comparison with traditional multiport laparoscopic cholecystectomy. DESIGN Ten patients underwent robotic single-port cholecystectomy performed with the da Vinci Si robot and novel da Vinci single-site instrumentation. Outcomes and operative times were compared with patients undergoing traditional multiport laparoscopic cholecystectomy during the same period. SETTING Tertiary care Veterans Administration hospital. PATIENTS Outpatients older than 18 years with an American Society of Anesthesiologists class of 1 to 3, no prior upper abdominal surgery, and diagnosis of noninflammatory biliary disease. INTERVENTION Single-site robotic cholecystectomy. MAIN OUTCOME MEASURES Operative time, complications up to 30 days, pain scores, and overall satisfaction. RESULTS Nine of 10 patients had completion of robotic single-site cholecystectomy. Average operating room time was 105.3 minutes compared with an average of 106.1 minutes in the standard laparoscopic group. There were no serious adverse events in the robotic surgery group, with an average follow-up of 3 or more months. CONCLUSION Robotic single-port cholecystectomy is feasible and comparable with standard laparoscopic cholecystectomy in the Veterans Administration medical center setting.

Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication

BACKGROUND Recently, investigators have reported the use of endoscopic myotomy in the treatment of esophageal achalasia. As with the open operation, considerable disagreement exists regarding the appropriate length of the myotomy and the need for a concomitant antireflux procedure. METHODS Patients presenting with symptomatic achalasia between 1993 and 1997 were included in this prospective study. Preoperative studies included barium upper gastrointestinal study, endoscopy, and esophageal manometry. Laparoscopic myotomy was completed in all 20 patients; 18 had concomitant Toupet fundoplication. RESULTS Operative times ranged from 95 to 345 minutes (mean 216). Blood loss ranged from 50 to 300 cc (mean 100 cc). There were 7 minor complications (5 mucosal injuries repaired laparoscopically, 1 bile leak and 1 splenic capsular tear). Nine patients began a liquid diet on the first day postoperatively; 19 were tolerating liquids by postoperative day 3. Hospital stay ranged from 2 to 20 days (mean 5). Eighteen patients had complete relief of dysphagia, with less than one reflux episode per month. One individual continues to have mild persistent solid food dysphagia. Another patient initially did well but subsequently developed mild recurrent dysphagia and reflux. One patient required laparoscopic take-down of the wrap because of recurrent dysphagia and now has no problems swallowing, but does complain of mild reflux. Two other patients also have mild reflux, 1 of whom did not undergo fundoplication. CONCLUSIONS Laparoscopic Heller myotomy can be performed safely with excellent results in patients with achalasia. Adding a partial fundoplication appears to help control postoperative symptoms of reflux. This procedure should be considered the procedure of choice in patients with symptomatic esophageal achalasia.

Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours.

BACKGROUND The first objective of this study was to identify risk factors in pregnant patients suffering blunt trauma predictive for uterine contractions, preterm labor, or fetal loss. The second objective was to identify patients who can safely undergo fetal monitoring for 6 hours or less after blunt trauma by selecting out those patients demonstrating the identified risk factors. METHODS A retrospective chart review was performed from January 1, 1990, through December 31, 1998. Charts were reviewed for numerous possible risk factors for adverse outcomes. Statistical analysis was performed by using logistic regression. RESULTS A total of 271 pregnant patients admitted after blunt trauma were identified. Risk factors significantly predictive of fetal death included ejections, motorcycle and pedestrian collisions, maternal death, maternal tachycardia, abnormal fetal heart rate, lack of restraints, and Injury Severity Score > 9. Risk factors significantly predictive of contractions or preterm labor included gestational age >35 weeks, assaults, and pedestrian collisions. CONCLUSION Pregnant patients who present after blunt trauma with any of the identified risk factors for contractions, preterm labor, or fetal loss should be monitored for at least 24 hours. Patients without these risk factors can safely be monitored for 6 hours after trauma before discharge.

Successful management of severe gastroesophageal reflux disease with laparoscopic nissen fundoplication

BACKGROUND Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken. PATIENTS AND METHODS Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders. RESULTS Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively. CONCLUSIONS These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.

Endoscopy Is Accurate, Safe, and Effective in the Assessment and Management of Complications Following Gastric Bypass Surgery

OBJECTIVES:Roux-en-Y gastric bypass (RYGB) is a common intervention for morbid obesity. Upper gastrointestinal (UGI) symptoms are frequent and difficult to interpret following RYGB. The aim of our study was to examine the role of endoscopy in evaluating UGI symptoms after RYGB and to assess the safety and efficacy of endoscopic therapy.METHODS:Between 1998 and 2005, a total of 1,079 patients underwent RYGB for clinically severe obesity and were followed prospectively. Patients with UGI symptoms after RYGB who were referred for endoscopy were studied.RESULTS:Of 1,079 patients, 76 (7%) who underwent RYGB were referred for endoscopy to evaluate UGI symptoms. Endoscopic findings included normal surgical anatomy (n=24, 31.6%), anastomotic stricture (n=40, 52.6%), marginal ulcer (n=12, 15.8%), unraveled nonabsorbable sutures causing functional obstruction (n=3, 4%) and gastrogastric fistula (n=2, 2.6%). Patients with abnormal findings on endoscopy presented with UGI symptoms at a mean of 110.7 days from their RYGB, which was significantly shorter than the time of 347.5 days for patients with normal endoscopy (P<0.001). A total of 40 patients with anastomotic strictures underwent 86 endoscopic balloon dilations before complete symptomatic relief. In one patient, a needle knife was used to open a completely obstructed anastomotic stricture. Unraveled, nonabsorbable suture material was successfully removed using endoscopic scissors in three patients.CONCLUSIONS:Patients presenting with UGI symptoms less than 3 months after surgery are more likely to have an abnormal finding on endoscopy. Endoscopic balloon dilation is safe and effective in managing anastomotic strictures. Endoscopic scissors are safe and effective in removing unraveled, nonabsorbable sutures contributing to obstruction.